EXSS is Exercising Science Solutions for Public Impact

Sport Related Mild Traumatic Brain Injury in the Pediatric Population

This week’s EXSS impact post highlights collaborative research between UNC-CH (Dr. Johna Register-Mihalik, Ms. Mackenzie Herzog, Dr. Valerie De Maio, Dr. Steve Marshall, and Dr. Kevin Guskiewicz) and colleagues at Carolina Family Practice & Sports Medicine (Dr. Josh Bloom and Ms. Janna Fonseca). This ongoing interdisciplinary and collaborative effort can help provide a better understanding of sport-related concussion in the primary care setting and the management and treatment options that may be most beneficial post-concussion in this setting.

What was the purpose of this study?

Traumatic brain injuries (TBI) among pediatric patients are serious events that result in significant burdens to both the health care system and the individual’s quality of life. As a result of the heightened awareness of sport-related TBI, more parents are seeking care for their child in the community practice setting following head injury for acute evaluation and to rule out more severe neurotrauma. There is limited understanding of the full severity spectrum and the outcomes for pediatric patients sustaining head trauma during sports activity. The aims of this study are to: 1) Compare the health-related quality of life (HRQOL) outcomes among pediatric patients presenting to the community practice setting with mild but without persistent symptoms, mild with persistent symptoms, and moderate-severe sport-related brain injury and 2) determine factors predictive of persistent symptom presence in pediatric patients presenting to the community practice setting following sport-related head injury.

What are we currently doing and what do we expect to find?

Approximately 400 injured patients (age 8 through 18 years), with a sport-related head injury mechanism, from the three practice sites will be included during a two-year study period. Eligible patients will be identified upon initial presentation to the practice setting for a head injury, within 72 hours of the injury, and complete informed consent at this initial visit. Participants will also have a study head injury form completed by a provider during this visit. The head injury form components provide information regarding patient demographics, past medical history, mechanism and injury characteristics, signs and symptoms, imaging results, and management plans. Participants will also complete a vestibular-ocular screening at this initial visit. Study personnel will contact participants at 14 days to provide a reminder about the study, and again between 4-6 weeks following the head injury to complete the 1-month follow-up survey. The follow-up survey will confirm patient and injury factors in head injury form, identify the clinical course since the injury, and determine HRQOL and other outcomes at 1-month post injury. Additional radiological data will be gathered for neuroimaging conducted outside of the initial visit presentation and within the first 30 days following injury. The primary outcome will be HRQOL (physical, emotional, social, school functioning and fatigue) measured with the parent-proxy of the PedsQLTM at 1-month post-injury. Secondary outcomes will include symptom presence (1-month post-injury), return to normal activities, and additional medical follow-up outside of the initial visit.

We hypothesize that for pediatric patients presenting to the community practice setting with sport-related head injury, mild TBI patients with persistent symptoms compared to mild TBI patients without persistent symptoms will have lower HRQOL scores at 1-month post-injury, but will have better scores than patients with moderate-severe TBI. We also hypothesize that patients with persistent symptoms at 1-month post-injury, compared to patients without persistent symptoms, will be more likely to be female, younger, have a past medical history of head trauma, have a pre-existing psychological condition, have an object to head injury mechanism, present to the community practice setting within the first 3-days following the current head injury with reports of headache, vomiting, amnesia, or loss of consciousness. As this secondary aim is exploratory, we acknowledge other predictive factors may emerge.

How do these findings impact the public?

To improve our understanding of HRQOL and risk factors for persistent symptoms among pediatric patients suffering mild TBI or concussion, we propose a prospective cohort study to follow all pediatric patients presenting to the community practice setting with any severity of sport-related head trauma. Failure to anticipate latent deficits for patients with mild TBI, may lead to inappropriate follow-up instructions and impaired decision-making for pediatric patients sustaining a sport-related head injury. Risk stratification for persistent symptoms may lead to improvements in the understanding of patient prognosis and provider decision-making for pediatric patients presenting to the community practice setting with sport-related head injury. The knowledge gained in this study will lead to better risk stratification and potentially reduce the morbidity associated with sport-related TBI by identifying patients who would benefit from early intervention, initial restrictions and specialized follow-up in the primary care setting, where a great majority of concussion patients first receive care.